Case Study: Ahrrythmias By Christine LaGrasta.
Welcome to today’s module on arrhythmias. My name is Christie LaGrasta. I work at Children's
Hospital Boston as a pediatric nurse practitioner.
So I’d like to go through a case study to put everything together. But as I read through
the slides, there are a number of questions to consider. The goal is to understand the
treatment choices base on the patient’s history, physical examination and response
to the treatments.
This is a case study for you to test your knowledge of arrhythmias we will ask you to
provide written answers. You will not receive formal evaluation on your answers, nor will
this count towards your certification status. Your answers will be used to assist us in
improving the teaching tools and lecture materials. You will be given a summary of the case study
at the end of the video to check your answers.
Case Study A 6 week old infant is brought to the hospital
because the mother thought he was having trouble breathing, was not eating well and he had
been vomiting. When you see the baby, he is breathing very fast. He is irritable and his
mother cannot console him. His color appears mottled and grayish.
Question 1: Does the baby need help?
Yes, this baby needs help. He is having difficulty breathing. He may be dehydrated if he has
not been eating well. The mottled color tells us his heart is not pumping enough blood to
the rest of his body or not pumping efficiently.
Question 2: What should you do first?
The first thing you need to do is to give the baby oxygen. Then put him on the heart monitor and place an intravenous
catheter or IV.
Question 3: What is your impression of this infant’s condition?
The baby is in respiratory distress. You give the baby oxygen and put him on the heart monitor.
The heart rate is 275 beats per minute, oxygen saturation is 99%, BP 72/55. You perform a
quick physical examination, the baby is still fussy and crying, and notice that the lungs sounds have crackles and the baby
is occasionally grunting, the pulses are weak, capillary refill time is delayed, the baby
is still fussy and crying and but the skin is less mottled.
This is the rhythm shown on the monitor: it is regular, but the p-waves are not visible.
Question 4: Is this a narrow complex or a wide complex rhythm?
This is a narrow complex rhythm. This is determined by measuring the QRS complex. When the QRS
complex is less than .08 seconds, it is narrowed.
Question 5: Why is this important to determine?
When the QRS complex is narrow, than the rhythm could be supraventricular tachycardia or a
sinus tachycardia. If the QRS complex is wide, the rhythm could be ventricular tachycardia.
This rhythm is a fast, narrow complex tachycardia with no visible p-waves.
Question 6: What is the diagnosis?
The diagnosis is supraventricular tachycardia.
Question 7: What is the treatment?
Follow the PALS algorithm for tachycardia. The first treatment will be to attempt Vagal
maneuvers: if ice is available place it on the baby’s face. Do not put it over the
baby’s nose. If this does not convert the rhythm to a sinus rhythm, give adenosine or
provide synchronized cardioversion. Point of clarification:
The general dose of Adenosine is initially
0.1 mg/kg rapidly IV/IO with a maximum dose of 6 mg. If there is no effect from the initial
dose, 0.2 mg/kg can be given rapidly IV/IO with a maximum dose of 12 mg.
Synchronized cardioversion is initially 0.5-1 J/kg. If not effective increase dosage to
2 J/kg.
Ice is placed on the baby’s face, but does not convert the supraventricular tachycardia
to a sinus rhythm. Adenosine is given through the IV.
The monitor now displays this rhythm.
Question 8: What is the rhythm now?
The rhythm is sinus rhythm. The rate is 165 beats per minute. The P waves are visible.
It is regular and all the intervals are of normal duration for a 6 week old baby.
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